ST. JOHN’S CLINICRolla, Missouri<br />
Lean Facility Design as an Agent of Organizational Change for the Future of Health Care<br />Randall Huss, MD <br />Presid...
Region and Market Information<br />Primary service area is four Missouri counties: Dent, Crawford, Phelps, Pulaski.<br />P...
St. John’s Clinic<br />550 physicians, 70 offices, 40 locations<br />Integrated physician arm of St. John’s Health System<...
St. John’s Clinic<br />Consistent Top 10 performer in Press-Ganeypatient satisfaction<br />CMS Physician Group Practice De...
St. John’s Clinic is becoming Mercy Clinic<br />1,300 integrated physicians<br />350 mid-level providers<br />4,000 co-wor...
Mercy Clinic Footprint<br />7<br />
History and Background<br />St. John’s Clinic-Rolla (2006-2007)<br />Outdated buildings needed replacement<br />Desire to ...
Leadership’s Decision and Mandate<br />St. John’s Clinic-Rolla (2006-2007)<br />Do not replicate MOB designof the past (ev...
Burning Platform for Organizational Change <br />
Organization’s Vision <br />Improve patient experience: patient-centered care, convenience and comfort<br />Efficiency and...
Design-Build Team Vision<br />Develop the facility of the future for ambulatory healthcare via partnering and collaboratio...
Health Reform Drivers<br />Patient and staff safety<br />Quality/outcomes<br />Access<br />Efficiencies: doing more with l...
Mercy: A New Model of Care for the Future<br />Improved chronic disease management<br />Multiple access points/vehicles fo...
Organization’s Drivers <br />Operational efficiencies<br />Improved access<br />Integrated, coordinated care<br />Team-bas...
Innovation<br />Seeing things differently<br />Doing things differently<br />Making a difference<br />Converting problemsi...
Barriers to Innovation<br />Traditional mindsets:<br />“Too risky…”<br />“Suppose it fails…”<br />“Impossible, never been ...
Gandhian Engineering<br />“Doing More with Less for more and more and more…” <br />R.A. Mashelkar: Breakthrough designs fo...
Nano - Tata<br />
Opportunity and Challenge<br />
The Ambulatory Health Care Facility…<br />…of the future<br />Efficiency<br />Design<br />Patient-<br />Centered<br />Tech...
Planning Challenges<br />Bringing together practices and services from three buildings<br />Integrating clinic, lab, imagi...
Planning Process <br />Must first understand EHR workflows and capabilities<br />Value Stream Mapping: Analyze patient vis...
Planning Process <br />If process (e.g. registration) is non-value added but necessary, can it be redesigned or improved?<...
Leap of Faith<br />Incremental or transformational change?<br />National trends<br />Cultural shift<br />
Leap of Faith<br />Incremental or transformational change?<br />National trends<br />Cultural shift<br />
Road Trip!<br />University of Utah Community Clinics “Learning Days”<br />Lead architect, senior Rolla division leadership...
<ul><li>Care Team Model
Lean workflow redesign for EHR
Call center serving10 sites
Redstone Clinic designed to Care Team Model
We liked it: we can do it!
Improve and notre-invent</li></ul>Road Trip!<br />
Keys to Success<br />Focus on patient experience<br />Right person / right job<br />Standardization<br />Lean facility des...
Workflow Redesign: The Care Team Model<br /><ul><li>LPNs/MAs trained to advanced competencies
Participate in EHR documentation
Off-load physician tasks
LPNs/MAs notassigned to oneprovider</li></ul>Patient/Nurse image<br />
Workflow Redesign: The Care Team Model<br /><ul><li>Up-staff LPNs/MAs per provider</li></ul>Provider and LPNs/MAs electron...
The Patient-Centered, Physician-Efficient Visit<br />Analysis of ambulatory office visit process from patient’s perspectiv...
The Patient-Centered, Physician-Efficient Visit<br />Eliminate waste<br />Eliminate steps:avoid provider leaving the room<...
Lean Workflow Redesign<br />Just-in-time (JIT) inventory, par levels<br />5S: sort, separate,shine, standardize,sustain<br...
Leverage Technology<br />Telemedicine rooms on each floor<br />Videoconferencing/webinar technology in multiple capacities...
Leverage Technology<br />Call center metrics and monitoring technology<br />My Mercy patient portal: Patient self-scheduli...
Leverage Technology<br />In-room checkout and next visit scheduling<br />Communications care team (aka “call center”)<br /...
Lean Facility Design<br />Analyze each element from Lean and customer perspective<br />Eliminate process ifnon-value added...
Lean Facility Design<br />Galleria: Patient-centered comfort; welcoming<br />Eliminate paperstorage space<br />Standardiza...
Lean Facility Design<br />
Lean Facility Design<br />Minimized greeting lobby over large “waiting room” <br />
Lean Facility Design<br />Private registration kiosk in galleria<br />
Lean Facility Design<br />2 levels with on-grade entrances/close parking<br />Amenities:Mercy Mocha,Wi-Fi, drive-uppharmac...
Lean Facility Design<br />Shared provider lounges over individual offices<br />Support Care Team model<br />Care Team modu...
Lean Facility Design<br />Avoid single purpose rooms<br />Telemedicine rooms are also regular exam rooms<br />Avoid “proce...
Lean Facility Design<br />Reduced storage: anticipate JIT inventory<br />Eliminate “break room”in each suite infavor of si...
Transformational Changes<br />Care Team model(Lean workflow redesign)<br />Care Team module(Lean workspace redesign)<br />...
Incremental Changes<br />Just-in-time inventory<br />Lean process improvement<br />Immediate lab results(stat spin)<br />F...
So…how are we doing?<br />
Patients<br />Press Ganey Patient Satisfaction<br />Significant drop first quarter <br />Increases each of last 4 quarters...
SPACE – 13% Reduction<br />CAPACITY – 16% Increase<br />Entire Building<br />Lean Facility Design Results<br />
SPACE – 20% Reduction<br />CAPACITY – 16% Increase<br />Clinic<br />Space<br />Lean Facility Design Results<br />
Facility<br />$3.8M<br />$420K<br />$170K<br />$3200<br /><13%<br />
Business Performance<br />>100% <br />+$2.8 M<br />> 50%<br />+6.2%<br />
Call Center<br />Up-training  <br />Upgraded salary structure<br />Increased nursing positions<br />Lean Project<br />4 mo...
Telephone Encounter: Scenario #1<br />
Telephone Encounter: Scenario #2<br />
Call Center Performance Metrics<br />Call center software<br />> 27,000 calls/month; 69% for issues other than scheduling ...
Lessons Learned<br />Call center conceptabsolutely right processimprovement strategy;did ultimately requireexecutive decis...
Lessons Learned<br />Challenge client toco-create change<br />Look to change deliverymodel systematically,not incrementall...
Evolving Culture <br />Accepting Care Team module<br />Facility supports co-worker events<br />Amenities<br />Open archite...
Visions/Goals<br />In-room direct EHRscheduling at other offices<br />In-room balance collections<br />In-room lab draw,sp...
Visions/Goals<br />Integrate/centralize Clinic,HOPD, pre-certification,billing andscheduling process<br />Achieve NCQAPati...
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Lean Facility Design as an Agent of Organizational Change for the Future of Health Care

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Presented on April 16, 2011 at the 2011 American Medical Group Management (AMGA) Annual Conference in Washington, DC
Presenters:
Dr. Randall Huss, President, Mercy St. John's Clinic - Rolla Division
Gerald Dowdy, Vice President, Mercy St. John's Clinic - Rolla Division
Whitney Churchill, AIA, Architect, The Neenan Company
Dan Garofalo, Vice President Business Development, The Neenan Company
Using the acclaimed and highly innovative St. John's Clinic - Rolla facility as the kick-off for discussion, the presenters described how the Lean facility design served to drive Lean process improvement and a new model of patient-centered care. Presenters provided one-and-half-year follow-up data, including voice of the customer surveys, patient satisfaction, call center metrics, provider feedback, and lessons learned. An emerging national trend in healthcare organizations utilizing Lean facility design, as well as results that can be obtained, was discussed.

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  • Appropriate graphics to be selected by NEENAN after we receive information from Dr. Huss (any additional information needed???)Presented by DR. HUSS
  • Dr. Huss – confirm or add information – Neenan to assist with graphicsEfficient: design, flow, function and processesFocus: Patient-centered comfort and careTechnology: Fully digital, leverages robust EHRProcesses: PaperlessDesign: Support new model of team-based and patient-centered careClinic and hospital partnership
  • Lean Facility Design as an Agent of Organizational Change for the Future of Health Care

    1. 1. ST. JOHN’S CLINICRolla, Missouri<br />
    2. 2. Lean Facility Design as an Agent of Organizational Change for the Future of Health Care<br />Randall Huss, MD <br />President, St. John’s Clinic-Rolla Division<br />Gerald Dowdy<br />VP, St. John’s Clinic-Rolla Division<br />Dan Garofalo and Whitney Churchill<br />The Neenan Company<br />
    3. 3. Region and Market Information<br />Primary service area is four Missouri counties: Dent, Crawford, Phelps, Pulaski.<br />Population: 2010: estimated 137,000 2015: projected 145,000<br />40-45% market share with >180,000 patient visits per year.<br />
    4. 4. St. John’s Clinic<br />550 physicians, 70 offices, 40 locations<br />Integrated physician arm of St. John’s Health System<br />St. John’s Health System ranked in Top 3 integrated delivery systems 2007-2011<br />
    5. 5. St. John’s Clinic<br />Consistent Top 10 performer in Press-Ganeypatient satisfaction<br />CMS Physician Group Practice Demonstration Project<br />4 operating divisions<br />
    6. 6. St. John’s Clinic is becoming Mercy Clinic<br />1,300 integrated physicians<br />350 mid-level providers<br />4,000 co-workers<br />4.4 million patient visits<br />$670 million in net revenues<br />360 offices in 4 states<br />
    7. 7. Mercy Clinic Footprint<br />7<br />
    8. 8. History and Background<br />St. John’s Clinic-Rolla (2006-2007)<br />Outdated buildings needed replacement<br />Desire to consolidate 3 sitesinto 1 building<br />EHR deployment upcoming<br />Desire to add outpatientservices (HOPDs)<br />
    9. 9. Leadership’s Decision and Mandate<br />St. John’s Clinic-Rolla (2006-2007)<br />Do not replicate MOB designof the past (even if others still building those)<br />Build ambulatory healthcare facility of the future<br />Efficiency: optimizeproject size (capitalconstraints), yet providefor maximumnumber of providersand services<br />
    10. 10. Burning Platform for Organizational Change <br />
    11. 11. Organization’s Vision <br />Improve patient experience: patient-centered care, convenience and comfort<br />Efficiency and flows: work smarter, not harder<br />Physicians: offload tasks to others working at top of licensure<br />Nursing staff: decrease steps and prep time<br />Achieve team-based care model<br />Integrate clinic and HOPD services:break down silos<br />
    12. 12. Design-Build Team Vision<br />Develop the facility of the future for ambulatory healthcare via partnering and collaboration<br />Follow Lean principles<br />Seek transformational design to support transformationalmodelof care<br />
    13. 13. Health Reform Drivers<br />Patient and staff safety<br />Quality/outcomes<br />Access<br />Efficiencies: doing more with less<br />Cost<br />Transparency and accountability<br />
    14. 14. Mercy: A New Model of Care for the Future<br />Improved chronic disease management<br />Multiple access points/vehicles for care<br />Transparency and accountability<br />ACOs and Medical Home<br />Demand for patient-centric care<br />Catering to needs of our key patient types<br />
    15. 15. Organization’s Drivers <br />Operational efficiencies<br />Improved access<br />Integrated, coordinated care<br />Team-based care<br />Leverage technology and new EHR<br />Build facilities that support new model of care<br />Innovation<br />
    16. 16. Innovation<br />Seeing things differently<br />Doing things differently<br />Making a difference<br />Converting problemsinto opportunities<br />
    17. 17. Barriers to Innovation<br />Traditional mindsets:<br />“Too risky…”<br />“Suppose it fails…”<br />“Impossible, never been done before…”<br />“Somebody has already tried it…”<br />“Let me play devil’s advocate…”<br />“My patients are different…”<br />
    18. 18. Gandhian Engineering<br />“Doing More with Less for more and more and more…” <br />R.A. Mashelkar: Breakthrough designs for ultra-low-cost products<br />less time<br />less resources<br />less space<br />less capital<br />
    19. 19. Nano - Tata<br />
    20. 20. Opportunity and Challenge<br />
    21. 21. The Ambulatory Health Care Facility…<br />…of the future<br />Efficiency<br />Design<br />Patient-<br />Centered<br />Technology<br />Processes<br />
    22. 22. Planning Challenges<br />Bringing together practices and services from three buildings<br />Integrating clinic, lab, imaging, pharmacy and new HOPD services (ASC, PT, sleep lab ) into “one stop shop”<br />Transformation from traditional office receptionist phone model to call center model<br />Design phase began prior to implementation of EHR<br />
    23. 23. Planning Process <br />Must first understand EHR workflows and capabilities<br />Value Stream Mapping: Analyze patient visit process from beginning to end from patient’s perspective<br />Apply Lean principles by eliminating waste, andnon-value added workand processes<br />
    24. 24. Planning Process <br />If process (e.g. registration) is non-value added but necessary, can it be redesigned or improved?<br />Must understand/do Lean workflow redesign before facility and workspace design<br />Leverage technology where possible: Don’t pave the cow paths<br />
    25. 25. Leap of Faith<br />Incremental or transformational change?<br />National trends<br />Cultural shift<br />
    26. 26. Leap of Faith<br />Incremental or transformational change?<br />National trends<br />Cultural shift<br />
    27. 27. Road Trip!<br />University of Utah Community Clinics “Learning Days”<br />Lead architect, senior Rolla division leadership,middle management and physician skeptic on3 separate visits<br />
    28. 28. <ul><li>Care Team Model
    29. 29. Lean workflow redesign for EHR
    30. 30. Call center serving10 sites
    31. 31. Redstone Clinic designed to Care Team Model
    32. 32. We liked it: we can do it!
    33. 33. Improve and notre-invent</li></ul>Road Trip!<br />
    34. 34. Keys to Success<br />Focus on patient experience<br />Right person / right job<br />Standardization<br />Lean facility design<br />Leverage andexploit technology<br />Effective communication<br />
    35. 35. Workflow Redesign: The Care Team Model<br /><ul><li>LPNs/MAs trained to advanced competencies
    36. 36. Participate in EHR documentation
    37. 37. Off-load physician tasks
    38. 38. LPNs/MAs notassigned to oneprovider</li></ul>Patient/Nurse image<br />
    39. 39. Workflow Redesign: The Care Team Model<br /><ul><li>Up-staff LPNs/MAs per provider</li></ul>Provider and LPNs/MAs electronic workstationsco-located<br />Move all functions notrelated to direct patient care out of suite <br />Only caregivers in the suite<br />Enhanced communication<br />
    40. 40. The Patient-Centered, Physician-Efficient Visit<br />Analysis of ambulatory office visit process from patient’s perspective<br />Optimize physician time and satisfaction <br />
    41. 41. The Patient-Centered, Physician-Efficient Visit<br />Eliminate waste<br />Eliminate steps:avoid provider leaving the room<br />Minimize patient movement:bring care to patient<br />Standard workflows, room layout and supplies<br />
    42. 42. Lean Workflow Redesign<br />Just-in-time (JIT) inventory, par levels<br />5S: sort, separate,shine, standardize,sustain<br />Standard room set-upand supplies<br />Procedure kits: allsupplies organized,quick grab-and-go<br />Printers in exam rooms<br />
    43. 43. Leverage Technology<br />Telemedicine rooms on each floor<br />Videoconferencing/webinar technology in multiple capacities<br />Training room<br />Videoconferencemeetings 110 milesfrom main campus<br />
    44. 44. Leverage Technology<br />Call center metrics and monitoring technology<br />My Mercy patient portal: Patient self-scheduling and messaging<br />
    45. 45. Leverage Technology<br />In-room checkout and next visit scheduling<br />Communications care team (aka “call center”)<br />Nurse protocols in call center for triage and refills<br />
    46. 46. Lean Facility Design<br />Analyze each element from Lean and customer perspective<br />Eliminate process ifnon-value added or ifmain purpose is to support paper workflows<br />Simplify wayfinding<br />
    47. 47. Lean Facility Design<br />Galleria: Patient-centered comfort; welcoming<br />Eliminate paperstorage space<br />Standardization: room construction, officesuite modules<br />Optimize square footage<br />Consider horizontal and vertical adjacencies<br />
    48. 48. Lean Facility Design<br />
    49. 49. Lean Facility Design<br />Minimized greeting lobby over large “waiting room” <br />
    50. 50. Lean Facility Design<br />Private registration kiosk in galleria<br />
    51. 51. Lean Facility Design<br />2 levels with on-grade entrances/close parking<br />Amenities:Mercy Mocha,Wi-Fi, drive-uppharmacywindow,patient-centeredcomfort <br />
    52. 52. Lean Facility Design<br />Shared provider lounges over individual offices<br />Support Care Team model<br />Care Team module: workspace redesign<br />Call center<br />Provide 3 roomsper provider on any given day<br />
    53. 53. Lean Facility Design<br />Avoid single purpose rooms<br />Telemedicine rooms are also regular exam rooms<br />Avoid “procedure room” designation<br />Exam room configuration to support technology<br />Flexible space: “swing rooms” between modules<br />Extra points of carepicked up withelimination ofindividual offices<br />
    54. 54. Lean Facility Design<br />Reduced storage: anticipate JIT inventory<br />Eliminate “break room”in each suite infavor of singleco-worker lounge(more amenities)<br />Sterile/non-sterilecorridor entrancesto operating rooms<br />
    55. 55. Transformational Changes<br />Care Team model(Lean workflow redesign)<br />Care Team module(Lean workspace redesign)<br />Communications care team(aka call center)<br />Partnership with HOPD operations<br />Co-located in the same building<br />EHR implementation – enabled transformation<br />Lean facility design – forces change<br />Minimizing waiting room, 70% less storage<br />
    56. 56. Incremental Changes<br />Just-in-time inventory<br />Lean process improvement<br />Immediate lab results(stat spin)<br />Fully digital imaging<br />Elimination of suite specific break rooms<br />
    57. 57. So…how are we doing?<br />
    58. 58. Patients<br />Press Ganey Patient Satisfaction<br />Significant drop first quarter <br />Increases each of last 4 quarters<br />All time Rolla achievement<br />Voice of the customer <br />76% rated experience as excellent / 21% as good<br />Wayfinding and layout / design <br />“One stop shop” healthcare<br />6% noted privacy concerns<br />Call center acceptance<br />Appeal of the facility<br />
    59. 59. SPACE – 13% Reduction<br />CAPACITY – 16% Increase<br />Entire Building<br />Lean Facility Design Results<br />
    60. 60. SPACE – 20% Reduction<br />CAPACITY – 16% Increase<br />Clinic<br />Space<br />Lean Facility Design Results<br />
    61. 61. Facility<br />$3.8M<br />$420K<br />$170K<br />$3200<br /><13%<br />
    62. 62. Business Performance<br />>100% <br />+$2.8 M<br />> 50%<br />+6.2%<br />
    63. 63. Call Center<br />Up-training <br />Upgraded salary structure<br />Increased nursing positions<br />Lean Project<br />4 month engagement<br />Evolutions of Solutions newsletter<br />Standardization of telephone process<br />Developed in basket performance goals<br />
    64. 64. Telephone Encounter: Scenario #1<br />
    65. 65. Telephone Encounter: Scenario #2<br />
    66. 66. Call Center Performance Metrics<br />Call center software<br />> 27,000 calls/month; 69% for issues other than scheduling appointment<br />95% call answer rate<br />< 1% voice mailbox message<br />Agent/call display<br />
    67. 67. Lessons Learned<br />Call center conceptabsolutely right processimprovement strategy;did ultimately requireexecutive decision<br />Communications care team and clinical care teams require continuous process improvement to maximize efficiency<br />Care Team module design challenge forDragon dictation<br />
    68. 68. Lessons Learned<br />Challenge client toco-create change<br />Look to change deliverymodel systematically,not incrementally<br />Technology changes everything<br />Lean facility design reinforcesworkflow improvements<br />
    69. 69. Evolving Culture <br />Accepting Care Team module<br />Facility supports co-worker events<br />Amenities<br />Open architecture promotes interaction<br />Clinic / Hospital fully integrated as a team<br />Voice of the customer (co-workers)<br />Overwhelmingly positive comments<br />Suggestions of TV in pediatrics<br />Common events<br />Photo Contest<br />
    70. 70. Visions/Goals<br />In-room direct EHRscheduling at other offices<br />In-room balance collections<br />In-room lab draw,specimen collection<br />Continue to reduce appointment rules and types<br />Implement touch screen self check-in kiosk<br />Continue to roll other clinics outside of Rolla into communication center <br />
    71. 71. Visions/Goals<br />Integrate/centralize Clinic,HOPD, pre-certification,billing andscheduling process<br />Achieve NCQAPatient-Centered Medical Homefor primary care offices<br />Billable e-visit<br />Continue Lean process improvement<br />
    72. 72. From Our Experience…<br />
    73. 73. Do<br />Continuously articulate a clear vision <br />Design for the norm,manage to the exception<br />Have an integrated team process between the design-build team, leadership team, providers and co-workers<br />
    74. 74. Do<br />Identify and enlist physician champions and participation<br />Include the voice of the customer<br />Design with the customer/patient in mind<br />Follow patient-centric concepts<br />Embrace Lean process improvement tools<br />Share the knowledge<br />
    75. 75. Do Not<br />Be in a hurry and build the wrong facility<br />Ignore the resistors – but do not allow them to hold design hostage<br />Underestimatethe challenges ofthe call center andco-worker skillsneeded<br />
    76. 76. Do Not<br />Be afraid toembrace change<br />Have sacred cows:instead, challengetraditional thinking in workflows, processesand design, andask why 5 times<br />
    77. 77. Conclusions <br />Implementation/optimization of robust EHR, combined with leveraging technology, provides opportunity for transformational change in model of care delivery<br />Innovative facility design provides opportunity to facilitate transformational organizational change and support a new model of care<br />Change is hard!<br />
    78. 78. The Prince<br />It must be remembered<br />that there is nothing more difficult to plan,<br />more doubtful of success,<br />nor more dangerous to manage<br />than the creation of a new system.<br />For the initiator has the enmity <br />of all who would profit by <br />the preservation of the old institution<br />and merely lukewarm defenders<br />in those who would gain by the new one<br /> Machiavelli, 1513<br />
    79. 79. Questions?<br />

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